J Pediatr Surg. 2010 Nov;45(11):2181-5.Antibiotics and appendicitis in the pediatric population: an
American Pediatric Surgical Association Outcomes and Clinical
Trials Committee systematic review.
Lee SL, Islam S, Cassidy LD, Abdullah F, Arca MJ; 2010 American
Pediatric Surgical Association Outcomes and Clinical Trials
Committee.
Division of Pediatric Surgery, David Geffen School of Medicine at
UCLA and Harbor-UCLA Medical Center, Box 709818, Los Angeles, CA
90095, USA. slleemd@yahoo.com
Abstract
OBJECTIVE: The aim of the study was to review evidence-based data
regarding the use of antibiotics for the treatment of appendicitis
in children.
DATA SOURCE: Data were obtained from PubMed, MEDLINE, and citation
review.
STUDY SELECTION: We conducted a literature search using
"appendicitis" combined with "antibiotics" with children as the
target patient population. Studies were selected based on relevance
for the following questions: (1) What perioperative antibiotics
should be used for pediatric patients with nonperforated
appendicitis? (2) For patients with perforated appendicitis treated
with appendectomy: a. What perioperative intravenous antibiotics
should be used? b. How long should perioperative intravenous
antibiotics be used? c. Should oral antibiotics be used? (3) For
patients with perforated appendicitis treated with initial
nonoperative management, what antibiotics should be used in the
initial management?
RESULTS: Children with nonperforated appendicitis should receive
preoperative, broad-spectrum antibiotics. In children with
perforated appendicitis who had undergone appendectomy, intravenous
antibiotic duration should be based on clinical criteria.
Furthermore, broad-spectrum, single, or double agent therapy is as
equally efficacious as but is more cost-effective than triple agent
therapy. If intravenous antibiotics are administered for less than
5 days, oral antibiotics should be administered for a total
antibiotic course of 7 days. For children with perforated
appendicitis who did not initially undergo an appendectomy, the
duration of broad-spectrum, intravenous antibiotics should be based
on clinical symptoms.
CONCLUSIONS: Current evidence supports the use of guidelines as
described above for antibiotic therapy in children with acute and
perforated appendicitis.

Surg Infect (Larchmt). 2008 Aug;9(4):481-8.Surgery for appendicitis: is it necessary?
Mason RJ.
Division of Emergency Surgery, Department of Surgery, Keck School
of Medicine of the University of Southern California and Los
Angeles County and USC Medical Center, Los Angeles, California,
USA. rmason@surgery.usc.edu
Abstract
BACKGROUND: Appendectomy for acute appendicitis is an effective,
universally accepted procedure performed more than 300,000 times
annually in the United States. It is generally believed that
appendicitis progresses invariably from early inflammation to later
gangrene and perforation, and that appendectomy is required for
surgical source control. Although non-operative management with
antibiotics of uncomplicated diverticulitis, salpingitis, and
neonatal enterocolitis is now established, the non-operative
management of appendicitis remains largely unexplored.
METHODS: Systematic review of published literature and derived
expert opinion.
RESULTS: Clinical, epidemiologic, radiologic, and pathologic
evidence is presented for spontaneous resolution of uncomplicated
acute appendicitis. The pathogenesis of appendicitis is reviewed
with specific consideration of the role of bacterial infection in
the pathogenesis. Evidence is also provided documenting the
clinical success of non-operative management.
CONCLUSIONS: Appendectomy may not be necessary for the majority of
patients with acute uncomplicated appendicitis, as many patients
resolve spontaneously and others may be treatable with antibiotics
alone. However, the supporting documentation is scant and of poor
quality. A randomized, prospective trial of non-operative
management versus early appendectomy of acute uncomplicated
appendicitis corroborated by radiologic imaging is called
for.

World J Surg. 2006 Jun;30(6):1033-7.Appendectomy versus antibiotic treatment in acute appendicitis.
a prospective multicenter randomized controlled trial.
Styrud J, Eriksson S, Nilsson I, Ahlberg G, Haapaniemi S, Neovius
G, Rex L, Badume I, Granström L.
Department of Surgery, Karolinska Institutet at Danderyd Hospital,
S-182 88, Stockholm, Sweden. johan.styrud@ds.se
Comment in:
• World J Surg. 2007 Mar;31(3):615; author reply 616.
• World J Surg. 2007 Apr;31(4):871-2.
Abstract
BACKGROUND: Appendectomy has been the treatment for acute
appendicitis for over 120 years. Antibiotic treatment has
occasionally been used in small uncontrolled studies, instead of
operation, but this alternative has never before been tried in a
multicenter randomized trial.
PATIENTS AND METHODS: Male patients, 18-50 years of age, admitted
to six different hospitals in Sweden between 1996 and 1999 were
enrolled in the study. No women were enrolled by decision of the
local ethics committee. If appendectomy was planned, patients were
asked to participate, and those who agreed were randomized either
to surgery or to antibiotic therapy. Patients randomized to surgery
were operated on with open surgery or laparoscopically. Those
randomized to antibiotic therapy were treated intravenously for 2
days, followed by oral treatment for 10 days. If symptoms did not
resolve within 24 hours, an appendectomy was performed.
Participants were monitored at the end of 1 week, 6 weeks, and 1
year.
RESULTS: During the study period 252 men participated, 124 in the
surgery group and 128 in the antibiotic group. The frequency of
appendicitis was 97% in the surgery group and 5% had a perforated
appendix. The complication rate was 14% in the surgery group. In
the antibiotic group 86% improved without surgery; 18 patients were
operated on within 24 hours, and the diagnosis of acute
appendicitis was confirmed in all but one patient, and he was
suffering from terminal ileitis. There were seven patients (5%)
with a perforated appendix in this group. The rate of recurrence of
symptoms of appendicitis among the 111 patients treated with
antibiotics was 14% during the 1-year follow-up.
CONCLUSIONS: Acute non-perforated appendicitis can be treated
successfully with antibiotics. However, there is a risk of
recurrence in cases of acute appendicitis, and this risk should be
compared with the risk of complications after appendectomy.

J Chir (Paris). 2009 Oct;146 Spec No 1:17-21. Epub 2009 Oct
28.[Can acute appendicitis be treated by antibiotics and in what
conditions?].
[Article in French]
Vons C.
Service de chirurgie digestive, hôpital Jean-Verdier, avenue du
14-Juillet, 93140 Bondy cedex, France.
corinne.vons@jvr.aphp.fr
Abstract
The current treatment for acute appendicitis is an appendectomy.
Several studies have, however, assessed the efficacy of an
antibiotic for treating acute appendicitis that is either
uncomplicated or complicated by local peritonitis. A meta-analysis
in 2007 that collected the results of 44 prospective studies showed
that antibiotics were efficacious in 92.8% of cases of appendicitis
complicated by local peritonitis, with percutaneous drainage of an
abscess when necessary. No predictive factor for failure was
identified. The failure of antibiotic treatment did not increase
morbidity. Over time and on the whole, the recurrence rate was only
8.9%. The risk of cancer of the appendix (1.5%) nonetheless led to
the recommendation of an interval appendectomy for adults. Four
randomized controlled trials have compared antibiotic treatment
with an appendectomy for the treatment of uncomplicated acute
appendicitis. The efficacy of the antibiotic treatment ranged from
86 to 100% and the recurrence rate from 10.4 to 35%. These studies
have had various methodological impediments; however, too few
patients were included (40 and 80 patients), or only a clinical
diagnosis was made before inclusion, or important protocol
violations occurred, in particular for almost half the patient in
the antibiotic therapy group in the 2009 study. These problems
prevent us from relying on these authors' findings. Antibiotics
have a role in the initial treatment of acute appendicitis
complicated by local peritonitis. In uncomplicated acute
appendicitis, the methodological inadequacy of the currently
available randomized trials makes it impossible to reach a
definitive conclusion about the efficacy of
antibiotics.